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Jt Comm J Qual Patient Saf. 2007 Feb;33(2):104-11.

Intralipid medication errors in the neonatal intensive care unit.

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University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, USA.


These findings suggest that most intralipids errors occur during the administration phase. This complex process can generate high opportunities for error directly related to the use of IV pumps. Nursing staff members are prone to making dosing errors while accurately programming the infusion devices, especially during times of high workload. The evening hours around shift change appeared most vulnerable to such errors occurring. A further analysis to include error rates as a function of error opportunities is critical. The tracking and tallying of such opportunity for error can be accomplished using smart pump technology. A detailed analysis of the existing intralipid administration workflow process will guide the overall strategy of an error prevention plan. Understanding the nursing workload as a function of time of day and census is essential. These mission-critical tasks often require the hard work of a dedicated task force, the commitment of the hospital leadership, and cooperation from the health care providers.

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[Indexed for MEDLINE]

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